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Dr. Ramesh Kekunnaya:
>> This is a 6-year-old girl who has, again, a bilateral cataract. We examined the parents. They don’t have anything. But the only thing you can look at here is the morphology. You can see that triad area of opacity with the multiple minute opacities within the lens. So, a little bit of atypical morphology, and she is fixates well aware, and her firmness is visible and visual acuity is not so bad, it’s 6/60. But still — she needs — it’s visually significant. She needs surgery. We are going to implant. She is on the — from the lens point of view she is on a little bit of the hard side. 25.04 at this area is a little bit unusual. And we have that. We are going to implant the artificial lens in this case.
So the only thing here that is atypical is the morphology. You will see, as we are going forward. You can already see in the red glow. You can see it’s almost not visible without the collimator.
>> And you did a full EOA on this child before you began with biometry, correct?
>> Yep.
>> So, what did you find?
>> So, one of the things we did not do a complete one. If the infant is there, if the child’s age is less than one year, then we will to a corneal diameter. We’ll do a corneoscopy and the interocular pressure. In this patient everything else is normal, so we would not do a detailed anesthesia in this particular case.
So, this is the median neurotomy opening on one side. And that’s the second side. Just an entry is enough. Again, we’ll try with the same — same capsulorhexis for sepsis if we can, otherwise we’ll extend the wound.
>> And, in children do you ever use Trypan blue? Do you ever feel that you need a stain?
>> Yes, my training it was used in every case. Personally I use it only in total cataract cases. But I definitely suggest that everybody should use Trypan blue. I personally don’t use it because once you get experience, you want to be as minimal in terms of injection of intracameral agents. I do avoid it.
Otherwise I would suggest all the trainees, until they get experience, they should use it. So, what I have done is I’ve inflated the anterior chamber now. So, you can see this minute opacity within the lens. It’s very unusual to have an air bubble in this viscoelastic, but sometimes we get that. So, I’m going to go ahead with the small nick here.
This is the re-grasping forceps, actually. Used my myelin peeling. So, I’m trying to do that with capsulorhexis forceps. So, I’m trying to hold of that, you can see. So, this makes my capsulorhexis easier. Grasp and re-grasp. The red grow of the microscope is so good that I can see the extension or the progression of the rhexis.
>> And with the last case, full-time with the lamellar cataract, you said that you use that to size the CC —
>> Yes, that’s almost the same thing. But I don’t have any measurement here.
>> Right. So how are you using —
>> But you can see that the granules — opacities is granules. I don’t want to cross that. That’s where I put my margin. There is some extension here, so we need to pull it back. So, we are trying to pull it back. You can see. It comes back. With a little bit of pull it comes back. So, you should not go beyond the boundary of this granule as you can see.
So, this forceps makes my life easier. So, again, in this case I’m not going to do a hydro dissection.
>> Yes, sir. You’re going to do more of an irrigation aspiration and go peripherally and strip centrally?
>> Yes. Exactly. I’m going to take out this air bubble and the viscoelastic. It’s quite thick. You can see this. This visco you can see. So, now I’m going to go straight here. You can see out of 136 degrees. I’m going to go to the periphery first and pull out this material. There is no central nucleus here, but I still try to protect the central-most part because you don’t hit the posterior capsule. This is a protective phenomenon. The posterior capsule does not rupture like a cataract. But still there is a chance. Why take that chance if you can do a little bit different procedure?
Now, you can see the central disk is remaining. Now you can aspirate with the full — full pedal on.
>> Do you often switch — I see you don’t switch hands for your sub-incisional. You just maintain —
>> I switch. In the previous case, I switched.
>> Yes, sir.
>> Here, it looks like my thumb —
>> Yes, sir.
>> Can take care that have. Don’t hesitate if you are having a difficulty. In this case, it’s coming nicely, so, I’m not really moving it. You can see some few strands in the posterior capsule here. And this is where the cells are very, very prominent. You can see.
>> Yes, sir
>> See this? It comes.
>> And you mentioned that, obviously, this contributes to the risk of PCO.
>> Yes.
>> Do you feel this could also contribute to a risk of capsular phimosis?
>> Probably. The capsular phimosis —
>> Yeah.
>> Can form with the cells coming there.
>> So, what do you see as the risk factors, interoperatively. What do you worry about for capsular phimosis? Like a small rhexis —
>> Small rhexis, enacted vitrectomy, and lens design. As well as this capsule polishing. Okay. Now you can see that the right side of the capsule is not here. So, I’m going to switch the hands now. No point in trying with the same hand. Now I am switching from right to left. So, this is the irrigation. Goes first.
So, you can see the brownish colored. It looks a little bit brownish when you have this co-illuminator of the microscope on. It looks a little bit brownish.
>> Will you do the PPC first? Or put the lens first.
>> I’m trying to do the PPC first. I’m not happy with the capsulorhexis here. But I’ll try to do a PPC first. So, we’ll try. If you don’t, then we can inject the lens and then we can go ahead. You can see that small opening there. I’ll magnify. Yes.
>> So, sometimes at this situation, the interorbital constriction. Why? And how do you —
>> At this stage, if you have manipulated with the iris too much, then you’ll have constriction. Otherwise there is no reason that you should have constriction at this stage.
>> Sir, why you don’t do hydrodissection here?
>> It’s a good question. Nothing wrong in doing. I trained in India. We have a lot of total cataracts. So, when you have a total cataract, you will never know that there is a PC in any sense, specifically because of the posterior lenticonus. It really did not make any difference in terms of doing hydrodissection, in terms of reducing the time of surgery, as well as clearing of this capsular sense. That’s why I don’t do it.
But if somebody wants to do a hydrodissection, in these types of cases, you can safely do it. You know that all surgeons have some kind of preference, so, that’s what I would say.
It’s a nice heart there. A little love for Bangladesh. Okay. This is a fine forceps, so, you need to have a very fine moment. So, we can share that little bit of heart with the vitrector. Linear. 1,000 to 3,000. Great.
Okay. Can I have aspiration on, please, for a second. Maybe you can put visco there. So, now the visco is out. I want the vitrector, please.
>> Do you scan — is it all right to visualize the vitreous?
>> Okay. I don’t use it because, better to be minimally invasive as much as possible in terms of injecting drugs and drugs. Second thing is, the possibility of intraocular pressure rises. Post-surgery could be an option in this kind of situation. So, I don’t — I don’t use it.
So, now I want everybody to look at the flapping of the posterior capsule. That means I’m still not done with the vitrector, here. See that? Many vibrations. So, sometimes the children, the vitreous is so hard you need to do a little bit more. In this case I can see that the vitreous is solid. I still see some more fibers there.
okay now. It’s kind of stopped. So, other thing you can — this is one of the tips everybody can take. When you move like this, there should not be any peaking. See? I’m moving from one area to the other area. That’s another sign that you’re almost complete. So, I don’t know. Sometimes the air bubble comes. We don’t know from where. We really don’t know. Because they’re all pre-packed. We need to really inflate that bag. Now it is getting inflated. This is extremely important. Somebody was asking me the question. I need some more visco. It takes liters of visco to inflate the bag after vitrectomy.
So, I’m trying to inflate it especially — oops. I need an empty cannula. When you have a PPC, air bubble is not really welcome. It’s difficult. So, generally, the hospital gives one viscoelastic. I always insist on two. So whatever you use, you should insist on two. One of the things I do a little bit differently is I extend the same wound. Again, to save on addition wound as well as to save on suture. I extend this wound because we have done a study, scleral corneal, does not make a difference in terms of a stigmatism in a kid. Anyway, you’re going to take it out in a week’s time.
Yeah, there is some bubble there. But still we would like to inject the lens. Because it’s mainly in the superior area. So, one of the things I inject this lens rather than using this technique. One technique. The reason, again, with each moment, it makes a moment vertically. So, I just want to have a full control so I generally inject that. You can be as low as possible. This lens has a good memory.
But I will be a little bit eccentric here. So, you can see, the most important step in this case is the injection of the leading haptic.
>> Yes, sir, getting that leading haptic in —
>> Once you have the leading gone inside, the trailing becomes just a nudge. Just give a nudge here. It goes back. So, give a nudge here as well. Sometimes it doesn’t open up. So, this goes here. Nudge it. So, once you have done that, a little bit of centration. You can see that a little bit eccentric capsulorhexis here. We had a little bit of pull there. But still it’s covering. You can see that everywhere it’s covered.
I’m still wanting the trailing haptic to go into the bag. I just don’t want it to be there. So, go from this area. Go behind. Push, push, push. Should go. Anyway. That should be enough. Now I need my manual on visco aspiration mode, please.
At this stage, if someone wants to be minimally invasive, you can go with your favorite Simcoe-cannula. With the cannula, you will have a very balanced thing. So, that’s not bad at all, because you have a bigger one there. So, you can go with that as well. Just a gentle tap on the lens. All the visco should come.
You can see the endothelial coating here. When I’m going a little bit — see that? It’s coming. But if it doesn’t come, sometimes you can go behind and take it out. It’s a possibility. See this? It looks fine. But still, always you’ll have some — some gone behind the lens. You would still have a little bit. You can see that. It’s coming. It’s coming. So, if you really want sometimes, you can go there. Again, aspirate everything together.
Now, that looks okay. Air bubble, please. And we are going with the suture. Never go full thickness because you may be okay immediate post op. When you take out the suture, I have seen endothermitis happening because of this corneal infiltrate going into the intra-corneal. So, it may not look so bad when you do the surgery, but in the long-term. Think about long-term.
>> Yes.
>> Go partial thickness like this here. Partial. See that it’s partial here as well. See? Correct me, it’s partial. You can go a little bit longer.
>> Dr. Ramesh, I have a question that — how can you confirm that it is fully clear of vitreous —
>> Yes, your pupil will not be round. That’s one thing. And there will not be any peaking of the pupil. And your chamber will be deep. And your air bubble will not be round like this. It may be distorted. Translineal, that’s one thing you can use if you are really not sure. But I personally don’t use that.